Provider Demographics
NPI:1205022720
Name:BAIRANJE R NAYAK PHD OD INC
Entity type:Organization
Organization Name:BAIRANJE R NAYAK PHD OD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BAIRANJE
Authorized Official - Middle Name:R
Authorized Official - Last Name:NAYAK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-529-6699
Mailing Address - Street 1:1456 PARK AVE W
Mailing Address - Street 2:SUITE R
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2790
Mailing Address - Country:US
Mailing Address - Phone:419-529-6699
Mailing Address - Fax:419-529-6379
Practice Address - Street 1:1456 PARK AVE W
Practice Address - Street 2:SUITE R
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-2700
Practice Address - Country:US
Practice Address - Phone:419-529-6699
Practice Address - Fax:419-529-6379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4504/T1173332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2096155Medicaid
0791804Medicare PIN
OHU58797Medicare UPIN
OH2096155Medicaid